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SAN JOA* COUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY I0 # SERVICE REQUEST # gas station �lTvW�%0 U �✓� -/ JI"7 OWNER / OPERATOR HOME or MAILING ADDRESS 680 Quinn Ave EMPLOYEE M Anabi } 213-6026 CHECK if BtLUNG ZADDRESS FACILITY NAME Tracy Blvd Shell & Mini Mart ZIP 95112 Date Service Completed (if already co plated); SERVICE CODE: [ 9 O SITE ADDRESS 3725 N. Tracy Ivd Tracy, a. ? ! ® o v Payment Date a Street Number OftectIon StreelName Received :z city HOME or MAILING ADDRESS (If Different from Site Address) Street Number Stmot NaM* CITY STATE ZIP ENVIRONME HEALTH DEPARTM PHONE #1 EXT. APN # —7 LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE t ) oo CONTRACTOR / SERVICE REQUESTOR REQUESTOR Marty Weithman CHECK If BILLING ADDRESS BUSINESs NAME Service Station Systems PHONE# 408 EXT. 213-6038 HOME or MAILING ADDRESS 680 Quinn Ave EMPLOYEE M FAx# (408 } 213-6026 CITY San Jose STATE CA ZIP 95112 ED BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:DATE: 11/25/2014 PROPERTY/BusrNESs OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIzEDAGENT ✓Q Compliance Officer 1JAPPL/CANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: UST inspection PAYMENT COMMENTS: DEC #-2.2015 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE M DATE: } a ^ a J �✓ ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already co plated); SERVICE CODE: [ 9 O P I E: �2 nc6 Fee Amount: lb 01 �o Amount Paid ? ! ® o v Payment Date a Payment Type G `(_ Invoice # Check # 5-0 Received :z EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) T